Transitions

Gelane, Bri, Premal and I were super sad to say good bye to each other!
 I know we will keep in touch, but after 2 years of living, working, traveling together it was really hard to part.

It has been forever since I posted, I know, but I am going to try to get back into it.  You might have noticed that the description of my blog has changed (it is now "tales of my life as a pediatrician in Botswana and beyond....") I figured that was easier than setting up a new blog.  That is because I have moved to Cape Town, South Africa!  The Pediatric AIDS Corps program had 5 years of funding which ended in July 2011.  Other sources of funding were sought and the program transitioned to the Global Health Corps this July.  It will be very similar to the PAC program, but smaller and will focus on more than just HIV/AIDS.  Though it was quite hard to leave Botswana, all the patients at the clinic there, and the friends I have made in the last 2 years, it was time to move on.

I also had to say good bye to Gizmo our cat.  He clearly wanted to come along, but loves to be outdoors and I don't think he would have done well in a Cape Town flat.
Luckily Bilen moved in next door and Gizmo moved in with her.
They are both very happy now ;)

I have taken a job with an organization called South to South.  It is an NGO that is funded by USAID and is housed at the University of Stellenbosch in Cape Town.  The goal is to help South Africa expand their pediatric HIV program.  Many healthcare providers are comfortable treating adults with HIV but not children, so our goal is to help them feel comfortable treating children.  In addition, the goal is to increase the number of clinics that provide ARVs (medications to treat HIV) so that patients do not have to travel as far to reach the clinics or wait all day to be seen (do to overcrowding at the centers which exist).  You can read more about it here if interested www.sun.ac.za/southtosouth.I am the Pediatric Clinical Advisor which means I will be doing training and mentoring of healthcare workers (nurses, doctors, lay counselors, etc).  A lot of my time (about 40%) will be spent traveling around the country. Right now we are focusing on a district called Moretele which is in the Northwest Province of South Africa (about 2 hours north of Johannesburg), more on that in a few weeks after I have actual been.

Almost half of my residency class managed to make it to Sonia's wedding!

Sonia and Elliott are officially married

Before moving to South Africa, I was lucky enough to get to spend almost three weeks back in the States with family and friends.  I was really lucky that Sonia decided to get married during that time and so I got to attend her beautiful wedding and see a lot of my friends from residency (as well as two delightful new additions to our St. Chris family - Josie and Walter ;)

Josie, beautiful daughter of Meredith and Trevor

Walter, adorable son of Ruth and Robert

I spent lots of quality time with my parents, grandmother, aunts, uncles, and cousins.  Definitely the thing I miss the most about being "this side" is time with family and friends who are "that side" but luckily the technological age (skype, internet phones, etc) helps with that a lot.

I will try to post a few flashbacks of my last months in Bots and then will move on to giving you a sense of life in Cape Town.  Right now it is a lot of logistics, finding an apartment, buying a car, opening a bank account, etc but photos and details of all those things to come!

Adventures in April

The last week in April was an time for another adventure.  Josanna, Elizabeth, Bilen, and I drove from Gabs to Rustenberg, spent the night at a cute bed and breakfast and had our customary sushi dinner at the Cape Town Fish Market in Rustenberg.  The next morning we drove to Joburg arriving with plenty of time to sort out where to leave my car.  We ended up giving the car to Jacob a guy who works for a valet service at the joburg airport.  They have a business where they pick up cars at the departure terminal, take care of them (including washing them) and return them to the arrival terminal upon your return.  They came highly recommended by the owners of the Bed and Breakfast in Rustenberg.  Though I was still pretty skeptical of giving my car to a total stranger in a city known for car theft, it worked out!  He drove us from the airport to the bus terminal and was there with the car when we came back and it was cleaner than it has been in a long time!  Our bus was 1.5 late so we left Joburg at 11:30 pm and arrived in Maputo at 9:30 am the next day after an uneventful bus ride where we were able to sleep a bit.  From Maputo we got a ride to Bilene a beach town about 3.5 hr away.
Bilene was a really tranquil place.  Not too touristy.  We stayed at a place about a 45 min walk from town which was on the lagoon beach.  We spent three days relaxing at the beach, snorkeling with sea horses, and hanging out at a great local bar.  Chichunga's became our home away from home.  Each day we bought fish from women whose husbands had caught it that morning and Chichunga marinated it during the day and cooked it for us that night.  It was the best fish I have ever had (as you can see in the pictures, we did not leave any behind).
After 3 days, we rode back to Maputo and met up with Gelane (who had been to Cape Town with plans to run the 1/2 marathon - though those plans were thwarted by shin splints she still had a good time there). Maputo is a much busier city than Gabs, and a lot dirtier.  We took tuc tucs around the city, explored an old fort, ate at the fish market, and did a fair amount of shopping.  At night we found a great bar/club which had live karaoke and the following night a reggae band.  We had a minor run in with the police since we were not carrying our passports on our way to a club!  They pulled us over during a random stop (when we happened to have 6 people (including the driver) in a cab which is apparently not allowed, though many more unsafe modes of transport seem to be just fine) and told us that we were supposed to have our passports with us at all times.  After much hemming and hawing (I think they were just looking for us to bribe them), they finally agreed to accompany us back to the backpackers where we were staying so we could show them our passports and then they left us alone. There were also several run ins with giant rats everywhere we went, not the best when you are eating!
After another overnight bus ride back to Joburg we drove to the Drakensberg mountains (a mountain range on the border of South Africa and Lesotho).  It was gorgeous.  We stayed at a great backpackers where there happened to be the "Smoking Dragon's Women's Music Festival"that weekend.  48 hours of music from woman performers. It was great fun though we will have to go back to actually explore the Drakensberg since we didn't get to do any hiking.
Here is the trip in pictures: )

Training, Passover, and Tutoring

The very appropriate coaster that was on the presenters' table during our training.

The first week of April I was back to Bloemfontein, South Africa to do another training.  This time it was an Advanced Pediatric HIV Training.  Many of the nurses and doctors who attended had been at the basic training in February.  It was quite a challenge to explain concepts of antiviral drugs developing resistance to a group of mostly nurses who do not really have the background to understand it (resistance is a very complex topic even for specialists).  But we managed to make it a bit fun by having the participants act out the parts of virus and drugs to visually demonstrate.  Nevertheless many of the participants got to catch up on their sleep during the training, though we got a lot of positive feedback at the end and people did do better on the post test than they had on the pretest.

After a week in Bloemfontein, I returned to Botswana and got to celebrate another passover in Botswana.  This time Liz and Jon hosted a seder.  We could not find any matzoh this year (though there was some last year, I am not sure what happened).  So Liz actually made her own matzoh!!  And then she even crushed it up to make matzoh meal and matzoh balls which were darn good!  

Jon was a very entertaining seder leader

Gelane throughly enjoyed her first seder and first matzoh balls!

We had a lot of vegetarian dishes and I made a really good flourless chocolate cake (thanks to Mom for bringing me Scharfenberger chocolate which totally made it).  

We even had Leonard (one of the Infectious Disease doctor's almost 2 year old son) to find the afikomen.  (He lost his pants during an accidentally spillage earlier in the evening and was more interested in the wire bowl he found than in bargaining for something in return for the afikomen ;)  It was great to be able to celebrate with friends, though I did miss the crazy Scherzer/Reisman seders!

During April I also did a lot of tutoring (I was trying to teach multiplication to K.N. above).  We started a tutoring program for patients in our clinic as many of them are doing poorly in school (a combination of being sick a lot, missing school frequently for routine doctors visits, and developmental delay can happen from HIV itself - especially for those patients who were started on treatment later in life.)  We have recruited volunteer tutors from University of Botswana, among other places, and are now able to offer tutoring every day and on Saturdays.  I spent a few Saturdays in April trying to remember how to do calculus, explaining long division, and learning the capitals of African countries.

Yoga, Jazz, and Family

The gorgeous coast along the Garden Route

The kids who guided us to the elusive eye

The last 2 weeks of March were quite “busy” with vacation.  It started with a weekend yoga retreat.  I have luckily been able to continue my yoga practice here in Botswana, actually going a lot more than I did in the States.  I have a great local teacher and the classes are smaller so there is a lot of personal attention.  My yoga teacher’s teacher did the yoga retreat.  It was held in Groot Marico, which is a small town in South Africa about 2 hours from here.  The setting was ideal, a small retreat center in the middle of nowhere with no cell phone reception, delicious vegetarian meals and nice cottages.  Yoga was conducted in an octagon shaped building and as our faces were inches from the ground she mentioned that the floor was made of a cow dung/mud mixture!  Wish I hadn’t known that part of it, but it did not smell and was coated with some kind of oil to keep it together….The theme of the weekend was "the elements," which meant exploring the parts of us that are Earth, Fire, Water, Air and Space.  I was only around for the first 3 elements since the retreat was three days and we only attended for two.  Exploring the element of Earth meant collecting piles of dirt and staring at it for 15 mins, then spreading the dirt out and staring at it again for 15 min and then putting it back in a pile and seeing how we felt about it now that it was back in pile.  We then discussed how everyone felt about the dirt and what the earth element meant to us.  While I found the idea of the elements interesting and attempting to try to balance them in each of us is a very important and noble goal, staring at dirt, moving water, still water, candles, fire, etc took a lot of patience on my part, which was also a good exercise ;)  The yoga was great, again it was a small group so we got a lot of personal attention. We also took a trip to "The Eye" a crystal clear spring near the retreat place, it was quite an adventure to find as it is tucked into the brush along a dirt road (luckily we ran into those children above who pointed us in the right direction).  It was raining and cold, but that did not stop us from zip-lining and jumping into the nice cold water ;)

On Sunday I left the retreat by way of a packed combi (minivans used for public transport around South Africa) to travel to Johannesburg and meet my parents who had arrived a few days earlier. The following day we flew to George along the Southern coast of South Africa, rented a car and began to drive the Garden Route.  

The Garden Route is the stretch of coastline between Port Elizabeth and Cape Town.  It is a gorgeous drive filled with amazing mountain passes, beautiful beaches, and lots of good fish dinners (something I never get in Botswana)!  We spent the first two nights at an amazing B+B in Plettenberg Bay.  The owner was an amazing cook and the location was amazing.  While there we went to the Tsitsikama National Park and hiked to Storm's River Mouth and part of the way to the waterfall.  I even convinced my dad to go zip-lining! 

On the bridge at the Storms River Mouth

Along the way to the waterfall (we did not have time for the whole hike but the views were breathtaking)

We then drove on Route 62 which is the part of road that weaves in a out of the mountains on some amazing passes.  We spent one night at a lodge in the town of Oudtshoorn that was on an ostrich farm and even collected a few ostrich feathers.

Eric the Farmer

Between Oudtshoorn and Swellendam was the famous Ronnie's Sex Shop.  It is a bar/restaurant in literally the middle of nowhere that started as a joke and has now becoming a famous stop along the route. Had to get the classic photo of Dad on the disintegrating tractor in front.

A photo opportunity in one of the mountain pass

We arrived in Cape Town on Friday in time for the Cape Town International Jazz Festival which just so happened to be the weekend my parents decided to visit (what great timing).  We saw some amazing performances, among them: Hugh Masekela, Earth Wind and Fire and even my friend Matt who was playing with Citie a guitar player from Botswana (the first Botswana artist to perform at the Jazz Festival).

Hugh Masekela (sorry no matter what I do this picture won't rotate, so you will just have to turn your head ;)

Citie on guitar and Matt on sax

We spent four full days in Cape Town exploring.  From taking the cable car up Table Mountain to listening to a concert in The Botanical Gardens to eating amazing food it was an awesome time in a great city.

Dad smelling the flowers at the section of the Botanical Gardens designed for blind people (all the plants had powerful smells and signs about them were translated into Braille as well.)

The Philharmonic performed to a packed crowd of serious picnickers (these people were really hard core about the picnicking right down to the stakes which held wine glasses!)

My parents and their friends Richard and Bobbie Polton (who joined us in Cape Town) and were able to find some nice recycled art of their own with the master artists

Mom with a lion made of wire and beads at the Streetwires store (a place that has hired some the local artists who make all kinds of objects out of recycled cans, wires, beads, etc).  We purchased quite a number of recycled designs from local artists at a art fair we happened upon as you can see above.

He looks like a professional, eh?
There are tons more pictures and stories, but I wanted to get this up before the next adventure  (which starts tomorrow ;) Happy Passover and Easter to all (stories from this year's passover to follow ;)

March

Wow has it really been a month since my last post? Yikes time is flying....
Well the end of February brought another excellent teen club.  We started the day off with two inspirational speakers, one is a judge in Botswana (one of the first female judges) and the other a radio DJ.  Interesting combination, but they both talked about leadership and what makes a good leader.  Both had great messages about having good self esetem and the confindence you can do things because you can't be a good leader without beliving in yourself first.  The teens were very responsive to the messages and asked some good questions.  Then we took the older teens (16-19 years) to the pool.  Seeing as Botswana is a land locked country that is largely a desert, there are very few opportunities for the kids to learn to swim.  Only about half were interested in trying (all in the shallow pool at the Univeristy of Botswana) and the other half played group games with water balloons.  It was a lot of fun and since it was really hot outside, everyone was happy to get wet!

Bloemfontein from the air

The first week in March I went to Bloemfontein, South Africa to conduct a basic Pediatric HIV training. There were 31 health professionals at the training, mostly nurses, from all over the Free State (one of the provinces in South Africa which Bloemfontein is the capital of).  We taught them about pediatric HIV management.  Many are already taking care of HIV positive patients but some of the nuances of managing children with HIV (like disclosing their status to them) were new to them.  The training was a week long and well received.  There was not much to do in Bloemfontein during the hours we were not conducting the training so I spent a lot of time at the "waterfront" mall.  The water is a man-made pond with a water fountain (or "water mountain" as my boss's 2 year old son calls it) in it, but at least there were some decent restaurants.

The "water mountain" at Waterfront Mall

Last week I was back in Gaborone working at the clinic.  On Tuesday night we celebrated International Women's Day by attending an event to raise money for an organization set up to fight abuse against women.  Unfortunately most of the speakers were not very motivating, just talked about themselves.  But there were a few performances including one by Shanti-Lo (a stunningly talented transgender singer) who is becoming very popular in Botswana despite the country's conservative nature.  Hopefully the fact that they chose him to be the closing act is a sign of the possibility that there is improving equality and openness in the society as a whole, slowly but still....

The Elusive Black Rhino

Last weekend we decided to go to the Khama Rhino Sanctuary for the weekend.  I have been there many times since it is in Serowe (where I used to live), but I had never spent the night.  A group of 12 went up and we stayed at the wonderful chalets that they have.  There was also a great tree for tree climbing (as you can see above ;)

A really pretty ?grasshopper and a Daddy ostrich with babies

We went on a game drive on Saturday afternoon and saw plenty of wildlife.  We told our guide that we really wanted to see a black rhino since none of us had ever seen one.  In the sanctuary there are 35 white rhinos and only 3 black ones.  The black rhinos are also harder to spot as they eat from bushes so stay in the dense parts of the park while the white rhinos are grazers eating grasses in the more open areas.  He was on the look-out and managed to find many other things, but no black rhinos.

A lilac breasted roller in flight.
They have the colors of the Botswana flag under their wings, something I never noticed before

We even saw one of the oldest rhinos in the park.  Apparently, you can tell by the length and the straightness of their horns - the longer and straighter the horn the older the rhino. Above is a mama and her baby.  After 2 hours we returned to our chalets and began to prepare for the brai (South African way of saying barbecue).  I wanted to make roasted potatoes, but realized we had forgotten to bring oil.  So I headed to the restaurant (a few hundred meters from our chalets) to see if we could borrow some.  They were nice enough to let me have a small cup of oil and I started to head back to the brai.  As I stepped out of the restaurant I saw a black rhino staring at me!  I shouted to the others to bring the cameras and watched as the rhino tapped on the edge of the pool which was covered.  He was rescued as a baby, so is more used to humans than the other rhinos in the park and has grown accustomed to drinking from the pool outside the restaurant.   One of the park staff members came to remove a section of the pool covering for him and we watched as he stuck his head in the pool and drank.

I offered him some oil as well, but he was not interested ;)  After he finished drinking he began to walk towards us so we scattered.

We followed behind him for a bit and at one point he turned around looked at us and then sprayed the area around him to mark his territory.  It was quite entertaining.

We returned to our brai and had a great feast which included a nice fire on which to roast s'mores!

Long Time

Celebrating my birthday with karaoke night and great friends 

Has it really been more than 2 months since I have written a blog post?  Wow time is flying!  At the end of November I went back to the States since my mother was having her foot reconstructed (after 6 weeks on crutches she is now happy to have one foot free of bunions and neuromas), celebrate my birthday, and Thanksgiving.  It was great to see family and friends and stock up on some of my favorite supplies (M+Ms, esp the mint ones, peppermint patties and black beans ;)

In Khami Ruins, near Bulawayo, Zimbabwe. 

One of the few remaining walls at Khami Ruins.  The royal family apparently lived on elevated rock walls on top of the hill (anything they could do to make themselves appear better than the common folk....)

The month of December flew by with a trip to Bulawayo, Zimbabwe over Christmas to see a beautiful national park, rock paintings, and ruins of an ancient civilization (Khami Ruins).  I celebrated New Year's Eve weekend in Cape Town which was a lot of fun as it is one of the most beautiful cities ever!

New Year's Eve in Cape Town! (thanks to Alexis for picking out the perfect shirt ;)

I feel like I wrote about these trips since all the pictures are on facebook, but I guess I never did.
I still cannot believe that January is over, it feels like the new year started yesterday.
I have also been doing some work ;)  I am still learning a lot from my patients.  Here are a few interesting stories.
B.C. is a 17 yr old who is doing really well on his HIV medications.  He always has good adherence, his virus is suppressed and he was a seemingly uncomplicated patient.  When I saw him at the end of December he said he had no issues, his physical exam was normal and his blood work looked good.  We talked about school (he is in Form 5, which is the last year here) and he said it was going okay, but that he wasn't doing as well as he wanted to be doing. He has been getting Bs (which is considered excellent here, esp at our clinic where most patients are getting Ds or Cs).  I told him about the tutoring program which we recently started to help kids with their school work since many of them are doing poorly and spend a lot of time at the clinic waiting for the doctors, medications, etc. He was excited and we agreed that he would meet the volunteers coordinating the program that day.  As I was printing out his note he said "you know I actually have been feeling kind of empty recently."  I turned around.  "What has been going on?" It then came out that he has been feeling depressed, has tried to commit suicide (he tried to drown himself in the bath tub) and is having a terrible relationship with his older brother who is his primary caregiver.  After several hours of discussion, involving our clinic psychologist, calling his aunt who came in (when I called her at work she dropped everything and came right away - she had sensed something was different, but did not know what to do and he had not told her anything), we worked out a safety plan.  He said he was feeling a bit better having told people and both he and his aunt felt that he could be safe at home.  He came back the following week and was feeling better having spent the Christmas holidays with his family in the north of Botswana.  He is now coming several times a week for tutoring, has brightened-up considerably, and has really formed bonds with the volunteer tutors.

I also got some sad news.  B.R. the very sick 10 month old whose house I went to back in Jan (see "Inreach" Jan 29) and who a few months later went missing has died.  We tried our best to track down the family last year, getting the local social worker and even the police involved, but we were unsuccessful.  This week our in-reach team was finally successful in contacting the mother's boyfriend who told them that the child had died.  We do not know what happened and still have not been able to contact the mother (according to her old boyfriend she does not have a cell phone) and get her care.  It is incredibly sad to know that B.R. most likely would have been fine had she been able to get her medications.  But unfortunately medications only work if you take them and sometimes there is no way to get that to happen.

Other times we are more successful.  P.S. is a 6 yr old who was admitted to the wards in January with severe pneumonia and Tuberculosis.  At an outside hospital they asked the family for permission to test for HIV and the parents declined.  However, since it was medically necessary to know, the hospital sent the test anyway and it came back positive.  The child was very sick so she was transferred to Gaborone.  When she arrived the team disclosed the positive diagnosis to the parents (it had not been disclosed at the outside hospital) and the parents were quite upset with the fact that the child had been tested despite their objections.  The reasoning was explained to them, but they refused to believe the diagnosis and refused to have her retested.  The ward team spent a lot of time with the family and the child recovered from her acute illness but they were still unable to convince them of the HIV positive status and need for treatment.  So they sent the family to our clinic for further counseling.
The nurse manager and I spent 2 hours trying to explain things to the parents, get them to consent to re-testing (so they could believe the diagnosis) and get them to test themselves.  The father (and culturally he spoke for the mother who refused to make any decisions without him) was adamant that no tests be done and wanted to have the opportunity to take the child to a church in South Africa to pray for her.  He is a primary school teacher and did have a basic understanding of HIV and said that he did not believe that praying could cure HIV, but he wanted the opportunity to pray for his sick child.  After much discussion and talking with the wards team it was agreed that the family would take the child to South Africa for the weekend and then return to the wards to have further discussion.  When the family did not return to the clinic as expected the following Monday we called the father who said he was still not ready to have the child tested.  However, he eventually did bring the child back to the wards that night.  Further discussion reveled that he thought that I (and the rest of the doctors) were on a mission to prove that his child was positive for research purposes (though we had never mentioned research of any kind).  So our social worker (whom he had not met and did not associate with the clinic) spent 5 hours with the family trying to come up with a solution.  At that time we had gotten the child's CD4 count back and it was 20 (showing that she was incredibly immune suppressed and needed to start treatment ASAP).  As this issue was quite urgent, they told the father that they might have to involve the police and what little child protective services there are here if he did not agree that the child needed treatment.  At that point the father took the child and the mother and stormed out of the hospital.  We were all worried that we had lost them and were planning to contact the police to try to find them.  However 24 hours later, the family returned.  The father had taken them all to a local testing center and they had all been tested and came back positive.  He brought the results to the hospital ward and apologized to the ward team for not believing them.  The next day we started the child on medications and the parents will go to have their CD4 count check to see if they need to start as well.  It has only been a week, but so far it seems that the family is giving the medications well and we remain hopefully that things will continue to go well.

So things are not always what they seem.  Sometimes the "stable" patients are actually the ones who need the most help and the ones who you think will never see the light eventually come around.  Of course, there are also the times, as in the case of B.R., when despite all of our best efforts we cannot reach an acceptable arrangement.  And I have also re-learned that sometimes patients just need time to come around and feel in control of the situation.  And of course gained even more appreciation for the importance of a team approach.